Nursing Diagnosis Flashcards
Three levels of care planning prioritization
1- ABC’s (airway, breathing, circulation)
2- Mental Status Changes; Acute pain
3- Unrelated health issues
What does prioritization mean?
Deciding which needs require urgent attention
Questions you should ask yourself while prioritizing
- What action will change the patient’s status right away?
- Is the task life threatening?
- Would another client be in danger if a task was left for later?
- Is the task essential to patient safety?
- Is the task essential to the client’s goals?
3 Components of care planning:
1- Identify priority problem
2- Provide etiology of problem
3- List the symptoms (subjective) and the cues (objective)
3 Elements of a care plan nursing goal:
- Simple
- Time limited
- Measureable
Elements for nursing intervention
- Determines elements of patient’s care for the day
- Includes action items for nursing staff
- Should be specific and able to be ‘checked off the list’
Elements for nursing rationale
- Determines ‘why’ we are listing interventions
- Completes the circle of evidence-based practive
- Should be scientific and based in evidence
- Should be simple and concise
3 parts of the ear
- External ear
- Middle ear
- Inner ear
What is included in the external ear?
- Pinna
- External auditory canal
- Tympanic membrane (eardrum)
What is included in the middle ear?
- Malleus, incus, stapes
- Eustachian tube
What is included in the inner ear?
Lybyrinth
Vestibule
Semicircular canals
Cochlea
Name for ear pain
Otalgia
What do we ask a patient when they have ear pain?
Location Character Cold symptoms or sore throat Injury or trauma Alleviating factors
Name for ear infection
Otitis
What do we ask patients about ear infections?
Number (adult or child)
Frequency
Treatment
Name for ear discharge
Otorrhea
What do we note about ear discharge?
If there is any Color Consistency Odor Any relationship between discharge and ear pain?
Subjective data we ask about hearing loss
Onset
Character
Situational
What can we see in our patient that may indicate hearing loss
Shouting Hollow sounds If they do a lot of airplane travel Family history of hearing loss Devices Coping strategies (tv up loud, etc.)
If pt does have hearing loss, what should we note about pt?
Lip reading Frowning or straining Posturing (turning head) Does not answer appropriately (says huh?) Irritable or startled Inappropriately loud voice Tone flat Television volume increasing
What do we ask patient about environmental exposure?
Any exposure to loud noises? Machinery Gunshots If they use ear protection *document occupation
Name for ringing of ears (spelling)
Tinnitus
What do we ask patient about ringing of ears
Onset
Occurrence
Amplification
Name for dizziness
Vertigo
What do we ask patient about dizziness
Onset
Associated factors
Alleviating factors
Has it happened before
What do we ask patient about self-care
Cleaning (do they use q-tips?)
Last exam
Devices
Characteristics of wet cerumen
Honey brown to dark brown
Moist
(Most common in African Americans)
Characteristics of dry cerumen
Gray
Flaky
Usually forms thin mass
(Most common in Asians)
Name for ear exam
Otoscopic exam
Difference between doing an otoscopic exam on an adult vs. a child
Adult - pull pinna up and back
Child - pull pinna down and back
What is the goal of an otoscopic exam?
Visualize tympanic membrane
What do we look at during inspection and palpation of external ear?
- Position upright/eye level?
- Size and shape (equal size, skin intact)
- Tenderness
- External auditory meatus (size of opening, no pain, tenderness, or erythema)
How do we assess if pt has tenderness?
Move pinna and push tragus
Should be firm and pain free
(If pain, could be swimmer’s ear)
What do we note while using the otoscope to examine?
- Redness or swelling
- Lesions or foreign bodies
- Discharge (color and odor)
What should the color of the tympanic membrane look like?
- Shiny and translucent
- Pearl gray color
- Cone-shaped light reflex prominent
What should the integrity of the tympanic membrane look like?
Should be intact
Scarring is indicative of repeated ear infections
What should the position of the tympanic membrane look like?
Flat
Slightly pulled in at center
What is the name for a middle ear infection
Otitis media
What is a middle ear infection?
Obstruction of Eustachian tube (doesn’t drain)
Geographically, where are middle ear infections most common?
North America
New Zeland
Group of people who most commonly get middle ear infections
Children
How are middle ear infections treated?
Multiple antibiotics prescribed
Can lead to antibiotic resistance - superbugs
Most common side effect of middle ear infections
- residual fluid in middle ear (post treatment)
- potential hearing impairment
- cognitive delay
Parental considerations about otitis media
Position is important
- Partly upright while feeding
- Do not prop bottle or let baby take bottle to bed
- Encourage breastfeeding
Name for swimmer’s ear
Otitis externa
How to perform the whispered voice test
One ear at a time while masking hearing in other ear Shield your lips Head 1-2 ft away Whisper slowly 2 syllable words
Normal: repeat of each word
What is the pupillary light reflex?
Normal constriction of pupils when bright light shines on retina
What is fixation?
A reflex direction of eye toward and object attracting person’s attention
Adaption of eye for near vision (Spelling)
Accommodation
What is accommodation?
Adaptation of eye for near vision
Medical term for cross eye?
Strabismus
Medical term for double vision
Diplopia
Self care behaviors to ask pt about eyes
Wear eye protection at work if welder, construction, etc.?
Take any eye medications?
Smoke?
Have you experienced any vision loss? How do you cope?
What position should pt be in to collect objective data about eyes?
- Standing for vision screening
- Sitting up with head at eye level
Equipment needed to collect objective data about pt’s eyes
- Snellen eye chart
- Handheld visual screener (used to occlude also)
- Penlight
How to perform far vision test
- Snellen eye chart
- Place chart in well-lit spot at eye level
- Pt stants 20 ft from chart
- Pt uses opaque card to shield one eye at a time during test
- Pt leaves on glasses/contacts
- Start with smallest lines
How to perform near vision test
- Use visual screener
- Hold card 14 inches away
- Distance equals 20/20 on Snellen
- Test each eye seperately
- Normal result is 14/14 bilateral
Test used to test pt’s peripheral vision
Confrontation test
How to perform the confrontation test
- Stand 2 ft away from pt
- Pt covers one eye
- Examiner covers opposite eye
- Use object and slowly advance from periphery in several directions
- Repeat for opposite eye
- Pt should see object at the same time as examiner
- Normal; Peripheral vision intact
Test used to examin pt’s corneal light reflex
Hirschberg test
What does the Hirschberg test do?
Assesses strength of eye muscles
How to perform the Hirschberg test
- Pt stares straight ahead
- Hold light 12 inches away
- Note reflection of light on corneas
- Reflection should be in same spot on each eye
Eye turned inward
Estropia
Eye turned outward
Exotropia
Eye turned upward
Hypertropia
Eye turned downward
Hypotropia
How to detect weakness in a particular eye
Cover test
What does the cover test test?
Detects weakness in a particular eye
Extraocular muscle function
How to perform the cover test
Pt stares straight ahead
Covers one eye at a time
Note uncovered eye
Normal response is a steady fixed gaze
What does the diagnostic positions test test?
Extraocular muscle function
How to perform the diagnostic positions test
Examiner guides patient
Object held at 12 inches
Patient to follow examiner movement with eyes only
Goal: Parallel tracking with both eyes
What do we look at when inspecting the patient’s eyebrows?
Symmetrical, present bilaterally
Moves with expression changes
What do we look at when we inspect a patient’s conjunctiva/sclera
Conjunctiva clear
Sclera china white
African Americans may have fatty deposits (normal)
What do we look at when we inspect a pt’s eyelids and lashes?
Normal overlap
Eyelashes are evenly distributed
What do we look at when inspecting a pt’s lacrimal apparatus?
No pain
Normal tears
Pushing on lacrimal apparatus shouldn’t produce tears
What do we note about the pt’s pupillary light reflex?
Size/shape
Normally pupils appear round, regular, and of equal size
(PERRLA)
What can we use to help us to remember what we should pay attention to when examining a pt’s pupils?
PERRLA (Pupils are Equal, Round, React to Light and Accommodation
How should you examine a patient’s pupil constriction?
How to document if it’s normal
Side to side comparison with pen light
Person gazes at a distance
Normal: direct and consensual constriction
How to test a pt’s accommodation
Person focuses on distant object
They shift gaze with your finger
For near and far vision
You look to see if their pupils constrict/dilate appropriately
What happens to someone’s pupils when using far vision?
Pupils dilate
What happens to someone’s vision when using near vision?
Pupils constrict
How to document normal pupillary response?
PERRLA
What does PERRLA stand for?
Pupils Equal Round Reactive to Light and Accommodation
What do we look at when inspecting occular fundus?
Red reflex
What do you use when inspecting ocular fundus?
Ophthalmoscope
What should pt’s pupils look like when examining with an ophthalmoscope?
Should see a flash of orange with red vessels
